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Education  |   July 2018
Anomalous Drainage of Inferior Vena Cava into the Left Atrium
Author Notes
  • From the Departments of Pediatric Anesthesiology (S.C.) and General Anesthesiology (S.K.), Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, Ohio.
  • Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (www.anesthesiology.org).
    Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (www.anesthesiology.org).×
  • Address correspondence to Dr. Chhabada: chhabas@ccf.org
Article Information
Education / Images in Anesthesiology / Cardiovascular Anesthesia
Education   |   July 2018
Anomalous Drainage of Inferior Vena Cava into the Left Atrium
Anesthesiology 7 2018, Vol.129, 191. doi:10.1097/ALN.0000000000002169
Anesthesiology 7 2018, Vol.129, 191. doi:10.1097/ALN.0000000000002169
ANOMALOUS drainage of the inferior vena cava into the left atrium is a rare cause of cyanosis in adults.1  The accompanying images exhibit this condition. Magnetic resonance imaging portrays the inferior vena cava entering the left atrium (top image). An ostium secundum atrial septal defect and a prominent left atrial eustachian valve are present (bottom image). Contrast injection into the inferior vena cava confirms anomalous drainage into the left atrium (video, Supplemental Digital Content, http://links.lww.com/ALN/B670, exhibits left atrial drainage of inferior vena cava).
Deoxygenated blood from the inferior vena cava empties into left atrium, resulting in venous admixture. The left ventricle ejects this admixed blood into the systemic circulation. The ensuing cyanosis and persistent hypoxemia lead to erythrocytosis and hyperviscosity.
Anesthetic management during noncardiac surgery focuses on minimizing cyanosis and optimizing cardiac output. Maintenance of normal systemic vascular resistance (SVR) is prioritized. High SVR increases left atrial pressures leading to decreased filling from the inferior vena cava. Consequently, cardiac output falls. Right to left shunting across the atrial septal defect worsens cyanosis. Such shunting occurs when SVR is low and pulmonary vascular resistance is high. Increases in pulmonary vascular resistance are minimized by employing low tidal volume ventilation and avoiding hypercarbia, hypothermia, and high positive end-expiratory pressure. Judicious use of vasopressors helps prevent precipitous decreases in SVR. Intravenous access in lower extremities is discouraged. Air emboli from the inferior vena cava enter the left atrium directly and can embolize systemically. Preoperative phlebotomy is considered if hematocrit exceeds 65% to minimize risk of thrombosis. Prolonged fasting worsens hyperviscosity and is best avoided.2,3 
Competing Interests
The authors declare no competing interests.
References
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